Management of
Gestational Diabetes
mellitus
Kapila Gunawardana
Definition
Gestational diabetes is
commonly defined as
glucose intolerance
first recognized during
pregnancy
Glucose metabolism &
pregnancy
 Due to placental production of anti-insulin
hormones, there is a state of insulin
resista...
Risk factors
1. Obesity
2. Previous history of GDM
3. Family history of diabetes
4. Racial origin
Asian and African-Caribb...
Screening & Diagnoses
75 g OGTT new diagnostics values
NICE/WHO IADPSG RECOMMENDED
mmol/l mg/l mmol/l mg/l mmol/l mg/l
FBS...
Maternal complications
 Cesarean section/Operative
deliveries/Trauma
 Pre-eclampsia
 Psychological morbidity.
 Recurre...
Fetal complications
 The accepted pathological mechanism by which GDM leads to
complications is known as the Pedersen hyp...
Rationale of treatment
o Its' treatment is also controversial.
o No clear guidelines and universally
accepted treatment pl...
Treatment plan
 Multi disciplinary approach
 Close monitoring & treatment of
GDM are very important for
mother & baby
 ...
Multi-disciplinary
approach
 Obstetrician
 Endocrinologist
 Physician
 Dietician
 Paediatrician
 Diabetic nurse.
Monitoring
FBS 1hr PPBS 2hr PPBS
mmol/l mg/l mmol/l mg/l mmol/l mg/l
NICE UK 3.5-5.9 63-106 7.8 140
ACOG 5.3 95 7.2 130 6....
Lifestyle modification
Dietary recommendations
Dietary pattern & calorie distributions
Breakfast- 10%
Lunch- 30%
Dinne...
Lifestyle modification
Exercise
 Women with gestational diabetes
often need regular, moderate
physical activity to help c...
Pharmacotherapy-
Insulin
• When diet and lifestyle modifications fail to control blood glucose within 1 to 2 weeks then
ph...
Pharmacotherapy-Insulin
regime
RCT found basal bolus regime gives better control
compared to twice daily regime.
Pharmacotherapy -OHA
 Metformin-(MIG Trial
Metfor. Vs Insulin in GDM)
& Glibenclamide (both
drugs safe in pregnancy,
both...
Antenatal care
Review every 1-2 weeks, more frequently if
complication ensue.
 Anomaly scan at 18-20 weeks
Serial ultra...
Antenatal care
Timing of delivery is controversial and if
uncomplicated can go up to 40wks.
However, decision should be m...
Intra natal care
GDM requiring pharmacological
therapy are best managed
intravenous insulin drips and
glucose monitoring ...
Postpartum care
Exclude persisting hyperglycaemia before
discharge ( FBS or PPBS)
Breast feeding should be encouraged & ...
GDM
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GDM

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GDM

  1. 1. Management of Gestational Diabetes mellitus Kapila Gunawardana
  2. 2. Definition Gestational diabetes is commonly defined as glucose intolerance first recognized during pregnancy
  3. 3. Glucose metabolism & pregnancy  Due to placental production of anti-insulin hormones, there is a state of insulin resistance  hPL , cotisol ,prolactin, GH ,estrogen and progesterone  Compare to non pregnant women  Low FBS with high PPBS  Low renal threshold for glucose & ↑ GFR leads to glycosuria  Increased production of insulin and high fasting insulin may lead to functional failure of the Pancreas
  4. 4. Risk factors 1. Obesity 2. Previous history of GDM 3. Family history of diabetes 4. Racial origin Asian and African-Caribbean 5. Maternal age more than 25 6. Previous macrosomic baby 7. Polycystic ovary syndrome 8. Multiple pregnancy
  5. 5. Screening & Diagnoses 75 g OGTT new diagnostics values NICE/WHO IADPSG RECOMMENDED mmol/l mg/l mmol/l mg/l mmol/l mg/l FBS ≥7.0 126 ≥5.1 91.8 ≥5.1 91.8 1Hr ≥10.0 180 ≥10.0 180 2Hr ≥7.8 140.4 ≥8.5 153 ≥8.5 153 75g OGTT Low risk group at 24 – 28 week High risk group at booking if normal again 24 – 28 week One abnormal value enough for diagnosis
  6. 6. Maternal complications  Cesarean section/Operative deliveries/Trauma  Pre-eclampsia  Psychological morbidity.  Recurrence risk of GDM is 30-50%  30-60% lifetime risk in developing , IGT or type 2 diabetes
  7. 7. Fetal complications  The accepted pathological mechanism by which GDM leads to complications is known as the Pedersen hypothesis  Macrosomia shoulder dystocia, birth trauma and related complications  Unexplained IUD  Polyhydramnios and PPROM or PROM  Metabolic complications Hypoglycemia, hypothermia, Ca2+, Mg2+, Polycythemia & Jaundice
  8. 8. Rationale of treatment o Its' treatment is also controversial. o No clear guidelines and universally accepted treatment plans available. o However randomized trials show benefits o in treating the GDM o The Australian Carbohydrate Intolerance Study (ACHOIS) was published in 2005 o National Institute of Child Health and Human development (NICHD) trial – USA 2009
  9. 9. Treatment plan  Multi disciplinary approach  Close monitoring & treatment of GDM are very important for mother & baby  Lifestyle modification  Pharmacotherapy
  10. 10. Multi-disciplinary approach  Obstetrician  Endocrinologist  Physician  Dietician  Paediatrician  Diabetic nurse.
  11. 11. Monitoring FBS 1hr PPBS 2hr PPBS mmol/l mg/l mmol/l mg/l mmol/l mg/l NICE UK 3.5-5.9 63-106 7.8 140 ACOG 5.3 95 7.2 130 6.7 120 5th international GDM workshop (2007) 5.3 95 7.8 140 6.7 120  You may have to test four times a day: 1. Fasting 2. 1 or 2 hours after breakfast 3. 1 or 2 hours after lunch 4. 1 or 2 hours after dinner
  12. 12. Lifestyle modification Dietary recommendations Dietary pattern & calorie distributions Breakfast- 10% Lunch- 30% Dinner- 30% Bed time snack- 30% Calorie -2000-2200kcal/day Normal weight:30kcal/kg Lean 35kcal/kg Obese:25kcal/kg) Composition: Carbohydrate - 40-50% complex, high fiber; Protein - 20%; Fat - 30-40%(<10%saturated)  A healthy diet is one that includes a balance of foods from all the food groups, giving the nutrients,  vitamins, and minerals necessary for a healthy pregnancy
  13. 13. Lifestyle modification Exercise  Women with gestational diabetes often need regular, moderate physical activity to help control their blood sugar levels by allowing insulin to work better.  Walking  Prenatal aerobics classes  Swimming  However, a consultation and approval by a health care provider is needed before beginning any physical activity during pregnancy.
  14. 14. Pharmacotherapy- Insulin • When diet and lifestyle modifications fail to control blood glucose within 1 to 2 weeks then pharmacological treatment should be commenced.
  15. 15. Pharmacotherapy-Insulin regime RCT found basal bolus regime gives better control compared to twice daily regime.
  16. 16. Pharmacotherapy -OHA  Metformin-(MIG Trial Metfor. Vs Insulin in GDM) & Glibenclamide (both drugs safe in pregnancy, both cross the placenta but no short term and intermediate fetal adverse outcomes.)  30-45% of patients in OHA need supplementary insulin to control their blood sugar.
  17. 17. Antenatal care Review every 1-2 weeks, more frequently if complication ensue.  Anomaly scan at 18-20 weeks Serial ultrasound from 28 weeks to detect fetal macrosomia. Monitoring of glucose every 1-2 week Frequency & timing of antenatal fetal monitoring is controversial . Complicated GDM needs early antenatal fetal monitoring as early as 32 wks. Can give antenatal steroids for fetal lung maturation and may need additional insulin
  18. 18. Antenatal care Timing of delivery is controversial and if uncomplicated can go up to 40wks. However, decision should be made according to the available informations. Mode of delivery will depend on the clinical as well as ultrasonographic evidence available. Diabetes should not be a contraindication for VBAC
  19. 19. Intra natal care GDM requiring pharmacological therapy are best managed intravenous insulin drips and glucose monitoring hourly . Others need only blood glucose monitoring during labour. Target blood sugar range 4-7mmol per l(72-126mg per l) Continuous fetal heart monitoring is advisable during labour.
  20. 20. Postpartum care Exclude persisting hyperglycaemia before discharge ( FBS or PPBS) Breast feeding should be encouraged & neonate blood sugar to be check 2–4 hours after birth. Lifestyle advice (including weight control, diet and exercise). OGTT at the 6 week. Every three year thereafter. Early screening for diabetes in future pregnancies. Contraception & preconception care.
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